The Therapeutic Alliance in Couple Therapy for Depression: Predicting Therapy Progress and Outcome from Assessments of the Alliance by the Patient, the Spouse, and the Therapists

This study examined Couple Therapy (CT) for depression in a naturalistic setting. It looked at the associations between the therapeutic alliance and subjective distress, and between the alliance and depression outcome. Twenty-nine depressive patients and their spouses were treated via CT. Treatments were adapted in accordance with the patient’s need. The couples assessed the alliance and their subjective distress at every session. In addition, the therapists assessed the alliance at every session. The patient’s depression outcome was assessed at baseline and at 6, 12, 18, and 24 months post-baseline. The Outcome Rating Scale, The Session Rating Scale, and the Beck Depression Inventory were used. At any given session, the patients’ and spouses’ deviations from their average subjective distress ratings predicted their deviations from their average alliance ratings in the same session. At any given session, the patients’ and spouses’ deviations from their average alliance ratings predicted their deviations from their average subjective distress in the next session. The therapy-system alliance was significantly associated with the patients’ depression outcome, explaining 19.4 % of the variance in the patients’ depression change. The results indicate the importance of taking into account the association between the alliance and subjective distress during the treatment, and confirm the usefulness of routine evaluation of the therapeutic process as an indicator of the association between alliance and therapy outcome in everyday CT for depression.     

Therapy with Families in China: Cultural Factors Influencing the Therapeutic Alliance and Therapy Goals

Rapid economic and social development in China is producing opportunities for a better standard of living for many families but also is associated with significant stress. Family therapy is one of the forms of mental health services that have become increasingly available. Western-derived models of family therapy are being used and adapted to meet the cultural traditions and needs of Chinese families. This article describes a variety of Chinese cultural factors that can influence the establishment of therapeutic alliances with family members (communication styles, collectivist values, family roles, and structure) and those that can shape family therapy interventions by addressing contextual factors affecting Chinese families (economic development, migration patterns, academic pressure, and changing gender roles for women). Suggestions are offered for using cultural sensitivity to address these factors tactfully to build strong therapeutic alliances and help families cope with significant life stresses.     

Revisiting Bordin's Theory on the Therapeutic Alliance: Implications for Family Therapy

Because of the belief that relationships are a major contributor to problems as well as the avenue for bringing about change, the alliance between therapists and clients is important in family therapy. Writings and ideas on the therapeutic alliance from psychoanalytic theory were used by Edward Bordin to develop a working theory in 1979, and later adapted to the field of family therapy. However, the adaptation did not account for many variables unique and important to family therapy. This article describes the therapeutic alliance and the necessity of creating a theory of therapeutic alliance that accounts for family therapy concepts. Future ideas for scholarship are presented.     

The Potential of Animal-Assisted Therapy Within the Supervisory Alliance

Chandler identified eight generalized benefits of animal-assisted therapy (AAT) for a person’s growth. These beneficial areas include (a) motivation, (b) distress tolerance, (c) alternative form of nurturance, (d) physical soothing, (e) genuine acceptance, (f) interactional enjoyment, (g) increased trust, and (h) increased encouragement to overcome barriers. Homestead identified supervision ideals, skills, and barriers within the supervisory alliance. If supervision is negative, this experience may disrupt the supervision relationship, process, and requirements. If not properly addressed, potential harm may come to the supervisee, supervisor, and possibly the client’s welfare. This review will identify how these eight areas of AAT may benefit the supervisory alliance to ensure the best care for the supervisee, supervisor, and the client.     

The Facilitation and Maintenance of the Therapeutic Alliance in Family Therapy

The formation and maintenance of the therapeutic alliance in family therapy involves complexities pertaining to the stabilizing tendency of family systems, and the necessity for negotiation of the goals and tasks of therapy with and among multiple individuals (i.e., the family members) in a context of systemic reciprocity and mutual influence. This article explores the complexities associated with the establishment and maintenance of the therapeutic alliance in family therapy. Alliance stances are presented as clinical applications designed to assist therapists in working with split alliances, establishing within family collaboration, and in negotiating homeostatic processes.     

Influence of Therapist and Client Behaviors on Therapy Alliance

This study considers the combined effect of therapist behaviors and couples interaction dynamics on therapeutic alliance because it seems to be a significant predictor of successful therapy outcomes. We measured therapeutic alliance using the Working Alliance Inventory, Observer Version (WAI-O), which includes three subscales: goals, tasks, and bond. We investigated the combined effect of therapist behaviors and couples interactions on therapeutic alliance. There were three significant findings: (1) the models better predicted therapeutic alliance for men clients than women clients; (2) combined consideration of partner behaviors and therapist behaviors provided the stronger prediction of therapeutic alliance; and (3) different variables predicted alliance for women clients versus men clients.     

Developing the Working Alliance in Marital Therapy; A Psychodynamic Perspective

A good working alliance in marital therapy is one in which the partners are actively collaborating with their therapist to work through conflicts. The therapist begins to develop the alliance by setting the frame of therapy and helping the couple understand the guidelines of treatment. The partners gradually identify with and emulate the therapist's working style and use of self as a reflective instrument. The working alliance can be weakened by empathic failures and strengthened by increased feelings of trust in the therapist and the process of treatment This paper looks at the development of the working alliance in marital therapy from a psychodynamic perspective. A clinical illustration is included.     

Ambivalence and Alliance Ruptures in Cognitive Behavioral Therapy for Generalized Anxiety

Client ambivalence about change (or motivation) is regarded as central to outcomes in cognitive behavioral therapy (CBT). However, little research has been conducted to examine the impact of client ambivalence about change on therapy process variables such as the therapeutic alliance. Given the demonstrated limitations of self-report measures of key constructs such as ambivalence and motivation, the present study instead employed a newly adapted observational measure of client ambivalence. Client statements regarding change (change talk (CT) and counter-change talk (CCT)) were coded in early (session 1 or 2) therapy sessions of CBT for generalized anxiety disorder. The frequency of CT and CCT was then compared between clients who later experienced an alliance rupture with their therapist, and clients who did not. The results showed that clients in dyads who later experienced an alliance rupture expressed significantly more CCT at the outset of therapy than clients who did not later experience an alliance rupture. However, CT utterances did not significantly differ between alliance rupture and no-rupture groups. CCT may strain the alliance because clients expressing higher levels of CCT early in therapy may be less receptive to therapist direction in CBT. Consequently, it is recommended that clients and therapists work together to carefully address these key moments in therapy so as to prevent alliance rupture and preserve client engagement in therapy.     

The Relationship Between Supervisee Stress,Coping Resources,the Working Alliance,and the Supervisory Working Alliance

The authors examined the relationship of perceived stress, specific types of coping resources, the working alliance, and the supervisory working alliance among 232 counselor supervisees. The working alliance and the supervisory working alliance were negatively related to perceived stress and positively related to multiple coping resources. Two regression models for predicting the working alliance and supervisory working alliance from perceived stress and specific coping resources were significant. Implications for practice and research are discussed.     

Examining the Relation Between the Therapeutic Alliance, Treatment Adherence, and Outcome of Cognitive Behavioral Therapy for Children With Anxiety Disorders

Little is known about the contribution of technical and relational factors to child outcomes in cognitive behavioral therapy (CBT) for children with anxiety disorders. This study investigated the association between treatment adherence, the child-therapist alliance, and child clinical outcomes in manual-guided individual- and group-based CBT for youths diagnosed with anxiety disorders. Trained observers rated tapes of therapy sessions for treatment adherence and child-therapist alliance in a sample of 52 children (aged 8 to 12) with anxiety disorders. Self-reported child anxiety was assessed at pre-, mid-, and posttreatment; parent-reported child internalizing symptoms was assessed at pre- and posttreatment. The results showed high levels of treatment adherence and child-therapist alliance in both CBT programs. Neither treatment adherence nor child-therapist alliance predicted traditional measurements of child outcomes in the present study, but a relation between alliance and outcome was found using a more precise estimation of the true pre-post differences. Implications of these findings for expanding our understanding of how treatment processes relate to child outcome in CBT for children with anxiety disorders are discussed.     

Competence in Delivering Cognitive Processing Therapy and the Therapeutic Alliance Both Predict PTSD Symptom Outcomes

Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1–3 and one session from Sessions 4–7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18–0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.     

Bilateral Art: Integrating Art Therapy,Family Therapy,and Neuroscience

This paper describes the systemic use of a neurologically-based art therapy modality—bilateral art—that engages both dominant and non-dominant hands in the process of creating images in response to opposing cognitions or feelings. It describes both neuroscience and family therapy perspectives that argue for the use of bilateral art. A specific protocol for bilateral art therapy is provided along with a case study demonstrating integration of the protocol into the systemic treatment of a young family. Carole M. McNamee, PhD, is Research Professor and Clinical Associate, Director of the Arts in Healthcare Project, The Family Therapy Center, Department of Human Development, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061 (cmcnamee@vt.edu).     

Computerised Cognitive Behavioural Therapy in an Adult Mental Health Service: A Pilot Study of Outcomes and Alliance

This pilot study aimed to explore the clinical outcomes and therapeutic relationship for clients of an adult mental health service using Beating the Blues, a computerised cognitive behaviour therapy (CCBT) package. Sixteen participants completed the programme and reported a significant reduction in Beck Depression Inventory scores posttreatment. Participants' mean item ratings on the relationship measure were above the neutral midpoint, but no association was found between the therapeutic relationship and outcome. The results are discussed in terms of the utility of CCBT as part of a stepped-care model and how further research might usefully explore the nature of the relationship formed between clients and CCBT programmes.     

Alliance Ratings as a Part of Trainee Evaluations Within Family Therapy Training

Client-reported therapeutic alliance scores were examined as a measure of improvement in therapeutic skills across master's-level marriage and family therapy (MFT) training. The results indicate significant correlations between alliance ratings and training variables, with the number of cumulative clinical hours identified as a significant predictor of alliance ratings according to a regression analysis. Trainees lacking the expected number of clinical contact hours in each level of training were found to be more likely to receive consistently marginal alliance ratings. Additionally, alliance ratings were especially useful in identifying trainees who were functioning at minimal levels of competency.     

Yosef Hayim Yerushalmi,the Royal Alliance,and Jewish Political Theory

This article examines Yosef Hayim Yerushalmi’s views of the realities and myths of the “royal alliance” in medieval and modern Jewish history as a seminal contribution to Jewish political history and theory as well as a revealing entrée into his overall historiographical approach. Elaborating the ideas of his teacher Salo Baron and drawing upon Hannah Arendt’s insights into the relationship between Jews and modern states, Yerushalmi ultimately used his own understanding of Jewish political experience to argue against her indictment of wartime Jewish leaders. For Yerushalmi, Jews’ awareness of their tendencies to forge vertical alliances with the highest authorities served to fortify and console them; he considered these perceptions generally realistic and, though at times tragically blinding, still ultimately anchored in historical experience. This essay situates the royal alliance within Yerushalmi’s broader conceptions of Jewish community, political agency, and domicile as diasporic survival strategies. It also views this concept as part of his post-Holocaust commitment to chart the paradoxes of Jewish hope and to regenerate Jewish hope, both collective and individual. Yerushalmi is often celebrated as a pioneering thinker who contrasted modern critical historiography to traditional collective memory and who explored the individual, existential, psychological, and skeptical dimensions of modern Jewish identity. Yet, this essay suggests, a traditionalist strain may be heard in his profound identification with the Jewish people and his deriving hope from their political and historical experience—in both its continuities and its ruptures.     

工作同盟和领悟对咨询效果的影响

为了解短程咨询中工作同盟和领悟对咨询效果的影响,以12个个案94次会谈为对象,考察工作同盟、领悟分别与会谈效果、治疗效果的关系,并考察二者共同作用于效果的方式。结果表明,咨访双方评定的工作同盟都可以正向预测会谈效果,但不能预测治疗效果;领悟与会谈有效性正相关,领悟正向预测治疗效果;咨询师评定的同盟的三个维度以领悟为中介影响其对会谈效果的评价。     

工人阶级、政治联盟与民主政治形成

民主政治在现代国家中得到普遍的确立,乃是政治发展进程中的标志性事件,工人阶级也不会自外于民主政治的形成过程,因而解释工人阶级与民主政治形成之间的因果关系就是一项富有价值的学术探险。本文秉持马克思关于工人阶级带来了民主政治的思想主张,在吸收社会科学已然呈现的成果的基础上,试图对工人阶级与民主政治形成之间的因果关系提供一个比较完整的理论解释。虽然现代国家中的民主政治并不是实现了政治平等与经济平等的实质民主,而只是实现了政治平等的形式民主,但是工人阶级仍然是民主政治形成的决定因素。当然,工人阶级在民主政治形成过程中发挥的决定作用,并不是指仅仅依靠工人阶级就能带来民主政治,而是指工人阶级联合中产阶级形成了支持民主政治的政治联盟,并且工人阶级是相比中产阶级而言更为坚定的民主政治的支持者,因此在工人阶级与中产阶级组成的政治联盟中工人阶级是中坚力量,扮演了领导者或者关键参与者的角色。     

Empty Depth,Empty Breadth,and the Forging of a Therapeutic Alliance

This paper describes a case in which analyst and analysand became interlocked in battles that drew out the 'mad' parts of each other. It explores how the extreme conflict may have actually been an integral part of what has become a truly therapeutic process for both. Theoretically, the dialectical movement of becoming through contradiction is used to help explicate how mutually destructive enactments were necessary building blocks of genuine intimacy.